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Chain Medicine

New Yorker writer and surgeon Atul Gawande on why a chain restaurant—the Cheesecake Factory– might be the new model for healthcare.

 a patient waits in the halls of the trauma unit of the emergency room at Grady Hospital in Atlanta. (AP)

A patient waits in the halls of the trauma unit of the emergency room at Grady Hospital in Atlanta. (AP)

Time was, every doctor in America was the lone practitioner, taking patients and doing medicine by his or her own lights.  A lot has changed.  It’s going to change more, says my guest today, writer and surgeon Atul Gawande.  The new model?

It may be a restaurant chain, the Cheesecake Factory, he says.  A huge menu, lots of outlets, lots of centrally-crafted recipes and control.  “Big Med,” he calls it, with cookie-cutter medicine and tons of central oversight.  It could raise quality and cuts costs.  Or not.

This hour, On Point:  Atul Gawande, on the chain restaurant model for health care.

-Tom Ashbrook

Guests

Dr. Atul Gawande, a surgeon, a writer, and a public-health researcher. His article on chain medicine appears in the current issue of the New Yorker.

Dr. Mark Girard, president of Steward Health Care Network, and a practicing interventional radiologist.

From Tom’s Reading List

New Yorker “The place is huge, but it’s invariably packed, and you can see why. The typical entrée is under fifteen dollars. The décor is fancy, in an accessible, Disney-cruise-ship sort of way: faux Egyptian columns, earth-tone murals, vaulted ceilings. The waiters are efficient and friendly. They wear all white (crisp white oxford shirt, pants, apron, sneakers) and try to make you feel as if it were a special night out. As for the food—can I say this without losing forever my chance of getting a reservation at Per Se?—it was delicious.”

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  • Wm. James from Missouri

    But do you have a drive-thru ? :)

  • Another Harvard physician

    In this interview, Dr. Atul Gawande projects a rather simplified and niave view of medicine.  What he failed to disclose are the differences between the Cheesecake Factory and hospitals.  For example, would the dining chain still serve a customer if he or she cannot pay?  Would the dinning chain still stay in business if it is required to have an “emergency feeding room” in an economically distressed section of the city without charity or government support.  Also, the number of diagnoses in medicine are significantly more than the number of dishes on the menu – compare the number of CPT codes with the number of dishes on the menu.  Medicine is far more complex than what was said in the interview.  Furthermore, having this discussion as an academic exercise that stimulates more research on this topic would be helpful.  But a public discourse without data that would lead to a change in public policy is disastrous and irresponsible.  Dr. Gawande is a surgeon, and surgeons tend to draw his/her experience on a case-by-case basis, as he cited his experience with his mother’s knee surgeries.  Remember, William Halstad was wrong in his thinking on the eradication of breast cancer.  It took a decade of clinical trials to prove that — but he was an excellent surgeon. 

    • http://pulse.yahoo.com/_HUHWX4TIAZRFNFYCWUE43OZDUQ 7LeagueBoots

       If the costs were reduced across the board and standardized there would be a much higher rate of repayment.

    • Tina

      Thank you!

  • Amie L.

    Setting aside for a moment the obvious connection between the food served CF and similar establishments, and the obesity epidemic’s impact on our healthcare system…

    I don’t think our system can continue with the medical equivanlent of Cheesecake-factory size entrees.  Meaning, if our healthcare system is to become sustainable, it will not be offering excessive “calories” (services, procedures, tests), only what has been clinically proven to be the best treatments at the least cost.

    • Tina

      We DO have to have a way of getting proper, up-to-date care for people with extremely expensive diseases or injuries.  As a nation, we HAVE to be prepared to all have a shared hand in disasters, be they hurricanes or major diseases.  Of course, people must be personally responsible enough to do their absolute best to avoid “courting” those disasters:  i.e., not smoking to help prevent lung cancer; not driving recklessly to help avoid a major car accident, etc.  But when a child is born with cerebral palsy, a system that included everyone would better spread out the life-time expenses of this kind of diagnosis.  

  • Che’ Riviera

    Single payer, medicare for all, universal healtcare.  Anything else is a bandaid, a diversion, a distraction.  Probably will not listen to this hour.

    • http://www.facebook.com/kyle.rose Kyle Rose

      You should wait for the “Bread line medicine” episode, then.

      • Che’ Riviera

        You should wait for the revolution, then.

      • http://pulse.yahoo.com/_HUHWX4TIAZRFNFYCWUE43OZDUQ 7LeagueBoots

         I’d rather have “bread line medicine” than what we have now.

    • Tina

      PLEASE LISTEN!  Your comments are so valuable to this forum!  I’d love to hear what you have to say about this hour!!! 

      • Che’ Riviera

        If you are not being sarcastic, I take your comment as a high compliment!

        • Tina

          I’m NOT being sarcastic, and my comment WAS meant as a compliment, but more so:  I wanted to hear your opinion on this topic!  We’ll probably disagree on some matters, but I’ve found, on a number of occasions, that you express ideas that I have, only you do so more clearly and succinctly.  I was just greedy for that on this topic!  (Hope that doesn’t make you self-conscious.)  I enjoy this forum so much because there is so much to learn from the intelligent people who post!  So, when you said you were bowing out of this one, I spoke up!!  I like learning how people from opposite sides of a policy think, but I REALLY enjoy seeing  how people who think as I do write about their ideas.  I like to learn more about topics so I can hone my POV, but I’m also interested in learning how to better express my POVs.   Thanks!

    • William

       Single payer system does not solve the problem we have right now. Who pays? Where does the money come from? Single payer via the government? or via private medical insurance companies? It still comes down to money..where to get the necessary funds to pay for “the other guy’s ” medical insurance or bills.

      • http://www.facebook.com/kyle.rose Kyle Rose

        There’s a more fundamental problem, which is that third-party payment disconnects price from cost: that is, if the patient doesn’t have to pay more for using more, what feedback is there to keep everyone from simply consuming more health care? This is a problem that exists with both the current managed care system and with a single-payer system.

        What is truly needed is an *insurance* system: one in which people pay the expected cost of their own health maintenance (thus encouraging them to prevent problems in the first place through diet and fitness) but are insured against unexpected events, such as fractures, cancer, etc. (This is the reason why, for example, orthodontics have poor insurance coverage: almost everyone gets braces at some point in their lives, so the cost amortized over the whole insurance pool is roughly equal to what individuals would pay on their own, anyway. Orthodontics are an expected cost, not an unexpected event.)

        • Che’ Riviera

          I don’t disagree with you, BUT…

          How does one gorge oneself on healthcare?  It isn’t like free government cheese and grabbing two blocks instead of one.  If someone is sick, treat them.  We aren’t talking about liposuction or rhinoplasty here. 

          • Mary

            You’d be surpised, but it can be done. If you don’t realize how much that treatment will cost.  5k for a cat scan 1100 ato 1800 for an MRI, people say.. yeah sure..

      • lodger

        Single-payer solves the problems of financing and access.  The money comes from taxes. 

        We already have single-payer in the US, and it  pays for half the amount spent on healthcare.  Read that again: our tax dollars are already paying half the $ we spend on healthcare.

        The big scam is that it covers only the most expensive people to cover, ie the ones the private insurance companies won’t profit from (e.g. elderly, disabled, indigent, war vets, active military, etc.). People like me pay twice: i buy my own insurance, and my taxes pay for the expensive groups mentioned above.

        Single-payer isn’t a pipe dream in the US, it’s already in place, but it benefits insurance companies by having taxpayers cover the bills for the most expensive patients.

        • Charles A. Bowsher

           No way can anyone convince that an Insurance Commission or an insurance companies overhead ever went to making someone healthier (other than financially).

      • Che’ Riviera

        This may seem overly simple, but we pay as a collective and share the healthcare available.  I work in healthcare and cannot possibly provide a detailed roadmap.  300 million americans divided by x funds equals available healthcare.  I think there is a large pool of universal healthcare systems across the civilized world for us to create our own model.  I’m even okay with the wealthy getting superior care, once everybody has acceptable basic care.  WE CAN AND MUST DO BETTER!

        • Charles A. Bowsher

           I call it “Wellness Care For All”. It’s part education, part healthcare, with responsibility for self holding it together.

      • http://pulse.yahoo.com/_HUHWX4TIAZRFNFYCWUE43OZDUQ 7LeagueBoots

         We currently pay taxes that are spent on things that don’t go back to the people who paid the taxes (which is what taxes are supposed to be for), and the current system means that there is the largest per capita expenditure on medicine of any country, despite this.

        Re-allocation of how currently existing tax money is spent and a standardization of healthcare would result in far better care and accessibility for far more people.

  • Corb

    Cheescake factory run the way the airlines are: Smaller seats, extra charges for baggage, sit down, shut up and get strip searched.

  • http://www.facebook.com/peter.newton.3956 Peter Newton

    It goes to prove my theorem: Over the last 30 years we moved from a public world to a private one in facets; Now, we are moving to a world of profitization, where only the profits matter.  When it is over, we will long for the halcyon days of the Robber Barons.

  • Petra

    Our question is how the standardization of medical practice, which is obviously sorely needed to improve quality and lower costs, will affect the patient-caregiver relationship. In this new world of big medicine, how do we keep the humanity in healthcare – and how do we support the caregivers?

    • Brian

      Building on Petra’s point, what role will employers have with health caregivers as the third party in the relationship? 

      For example, in the article Dr Gawande discusses Lowe’s relationship with the Cleveland Clinic. Lowe’s, Wal-mart, etc. are profitable because they squeeze the costs out of the supply-chain.  If a supplier is too costly, they get dropped for a cheaper alternative.  If Cleveland Clinic authorizes too many expensive heart procedures, will Lowe’s treat them like the would a screwdriver manufacturer and shop out a lower cost provider who might cut corners?

      • Mary

        the problem with that is that in Cleveland, the Cleveland Clinic is it.. HEre in Boston, we have a lot of different hospitals which provides competition.  IN other areas, forget about that. The market has been allowed to reduce it all to one health care provider.

        • Judy

          There is also University Hospitals, as well as numerous suburban hospitals in the Cleveland area.

  • TribalGuitars

    Why does it cost $1500 to fix a broken arm in one hospital and $5000 in one across town? Pay the docs and hospitals quick on the agreement that they  share their results, and say “this is how much we’re paying for a broken arm.”  That would inspire better efficiency and results, and cut costs.

  • Mary

    I read Dr. Gawande’s as usual excellent article. In between the lines, I saw a lot of  “I” instead of “we”.   Companies in the US have bought into the idea of the “team”  and as they say in the military there is no “I” in “team”. That must be addressed.- i.e. drs have to learn to be part of a cooperative team, and not neccarily the lead either.    There is also the article in the NY times about HCA, a hospital chain which has been caught giving people unnecessary heart treatments which exposed them to unnecessary risks.. all for $$$$!.. WE have to learn how to wean our doctors, both cardiologists and otherwise off of money.. Doctors in other countries don’t make nearly the money that doctors in the US make.   

  • Springbeg

    Chain medicine will never lower costs. The suits play the pricing game more aggressively. They also add a large layer of “management” costs to the overall burden.

  • Charles A. Bowsher

    Instead of looking to a restaurant for guidance, why not look at the foreign countries that are covering ALL their populations, with better results at lower per capita cost than the US?

  • http://pulse.yahoo.com/_Y6CO5C2HE4WM2OYGCDVWGPRXXM oldman

    When the Cheesecake factory has to make cheesecakes using multimillion dollar pieces of hardware that requires trained technicians and people the level of doctors to interpret the results, we can start comparing cheesecakes and medicine.

  • J__o__h__n

    England was fortunate that they had terrible food so instead of looking at a restaurant model, they set up NHS instead. 

  • Caitlin

    But the Cheesecake Factory serves, at best, mediocre food. Do we really want a healthcare system where, yes, the quality of care is consistent, but not all that great? By following a system like this, wouldn’t we eliminate any creativity and individual thought, which can mean the difference between life and death for a patient?

  • MarkVII88

    From my own experience working in Health Care, I can tell you that trying to manage doctors is like trying to herd cats.  When trying to enact large-scale changes there can be a lot of pushback and refusal to adopt new practices, especially when it conflicts with how a doctor has “always” done something and especially when the doctor feels like their freedom is being lost.  It is the (perceived) loss of autonomy that I believe really gets the back of physicians up to resist change, particularly older doctors who might just rather retire than fall-in-line.

  • TribalGuitars

    In France they have hospitals that are mostly dedicated to one main aspect like cardiology, or neurology, burns, trauma, etc. Not every hospital can be one, like in rural areas, but often in larger areas there are  many hospitals competing for business, scattering talent and losing focus instead. 

    Where I am we have a general hospital, but being more rural, but if, say, there’s someone in an accident and they have burn they gets flown to a hospital known for burn treatment, vs a child with trauma who gets flown to the childrens’ hospital, and so on for heart, or neurological trauma.

    • judy

      Yeah, if you took the “restaurant model”, no hospital can successfully offer every range of food successful.  Specialization creates higher performance.

      • TribalGuitars

        That’s funny because I used to work in a Chinese restaurant and we had two main kind of idiots:
        1 – The people that came in and ordered non-Chinese food exclusively. It wasn’t like 4 people came in and one didn’t want Chinese so they ordered a steak, all four would order steak, then they’d complain that the steak wasn’t to their liking.
          One night I couldn’t take it.  4 men complained about the steak and my boss, ever polite, was apologizing again and again as the ripped him up and down. I got between them and my boss ad informed them that it was a Chinese restaurant, not the Ponderosa steakhouse that was almost literally a stone’s throw away. 

        2 – People that thought real Chinese cuisine means an assembly line, MSG-laden, buffets that caters to American taste buds.  Then complain when the food doesn’t taste like they think it should. I don’t know how many times I had to explain that what we served is actually how something is supposed to be and why.

        • TribalGuitars

           My browser decide to post before I could finish:  anyway…

          The morals there were that if you want Italian food you go to an Italian restaurant, not McDonalds.

           We’re so used taking what we’re handed that we don’t know what better medicine is, let alone what better medicine is out there. The new migraine meds would be case in point. If doctors don’t use them, and possible don’t know about them, how are we supposed to?

        • J__o__h__n

          How was the Chinese food at the Ponderosa?

          • TribalGuitars

             Ponderosa had a problem with the lo mein. The noodles kept falling through the grill… 

  • http://pulse.yahoo.com/_Y6CO5C2HE4WM2OYGCDVWGPRXXM oldman

    There’s a great TED talk about a surgeon who went to Boeing of all places to find out how to do surgery better. Aviation uses checklists – he implemented simple checklists in  the operating room and got dramatic improvements in results and decreases in post-op issues. But the field as a whole is very reluctant to implement this even with proven positive results.

    • lodger

      That surgeon was Dr. Atul Gawande.

  • Jgeigerpho

    Let’s at least consider this.  For one thing a universal healthcare ID card would be astart – patient controlled of course.  I find my local Rite Aid pharmacy has more consistent record of my meds than any of my doctors.

  • Ellen Dibble

    Can the chief of the pit crew shift from a primary doctor to a specialist (surgeon, say) in a minute, if the records are electronic, with the critical points for the patient noted up top?  I hope so.

  • Lynne

    How is the pit chief different from the Primary Care Physician model = in which he/she was supposed to oversee care?

  • Stephen

    Atul, you make some good points – but you might rethink the Cheesecake factory analogy. It’s oh so easy to eat a >2000 calorie entree there, and then if you actually have a piece of cheesecake, well that’s another 1K calories or so. “Cheesecake factories” have contributed considerably to the obesity epidemic… Could they produce a healthier menu with as much success??? I wonder…

    • Steve_T

       I would go to a cheesecake factory Hospital, where they have contributed considerably to a health explosion where the menu is focused to produce healthier clients that would not visit as often. And the cost would be as much as a good meal. 

  • Judy

    Wasn’t this what the change to HMO’s back in the 80′s was supposed to offer….more standards of care that are more consistent?  That certainly has not worked out to the promise.

    I was recently admitted to the hospital after a bout of A. Fib., and the way my care was managed was a disaster.  My meds were messed up, even though the list was provided three times, to the ambulance crew, the ER nurse, and the admitting nurse.  I was not fed in the A.M., because I was supposed to have tests, but no one could say what they were.  When I saw my cardiologist, he said I could go home.  It took nearly 5 hours, and some pushing by me, before I was finally released.  Plus, that admittance will cost me $1500, versus $150 for an ER visit, which was all I needed.  

    • Ellen Dibble

      Maybe the hospital had an empty bed and needed the additional income — not the difference of $1,000 that you paid, but the difference in what your insurance pays to the hospital.  Oh, I’m a cynic at times.

  • Realist

    Let’s face it the reason why it medical care is not more rational and team based is because individual physicians want to bill for procedures as opposed to getting the best outcomes for patients.  This NYT article makes my point. http://www.nytimes.com/2012/08/07/business/hospital-chain-internal-reports-found-dubious-cardiac-work.html?_r=4&pagewanted=all&adxnnl=1&adxnnlx=1344348001-2git2DM4BgNiXUiZURFvag

  • Judithuk2002

    I think this sounds like a good way to standardize patient care.  Protocols are followed in hospitals in other countries (I have experience in the UK) and they are similar from one to another.  Patient records are more easily accessable from one medical provider to another too and so the patient is treated with more consistency.

  • MarkVII88

    In order for standardization programs and medical checklists to be successful at a medical institution, there must be the will to follow-through.  This means getting the actual physician groups on-board so that enforcing the standards is a team exercise, not just an edict from administration.  Under these circumstances, outliers and stragglers to adopt these practices can be guided back into line.  Unfortunately, this isn’t always the case and you just can’t force unwilling or unmotivated physicians to change without the right incentives.

  • Adks12020

    I’m a pretty healthy person so I haven’t experienced much medical care but it really surprises me that a system like the one being discussed right (system of steps and protocols) now isn’t is place in most places.  It seems like medicine, more than most professions, should have a system like this in place.  It’s an exacting science, isn’t it?

    • Leswp

      We used to have that in place until the hospitals started to eat up all the local practices and then fragmented care by making it all but mandatory to use hospitalists who have very little communitcation with the primary care provider either during or after admission.

  • Tina

    When did Physical Therapy start operating the way the guest described?  The Plan has always been a major component of PT treatment.  I really don’t know what he is describing with the comment that he made.  Thanks.

  • Springbeg

    With the cookie cutter model, there is no room for independent thinking. You simply follow the “recipe”. The problem is that people are different and unique. Doctor’s need to assert their professional status and resist the cookie cutter.

  • withheld

    I am a family physician who has worked in a large “cookie cutter” practice and now I am in a much smaller private practice.  While the large multi-specialty practice provided great, consistent care in the vein of the medical home model, I felt that the control I had over my own practice (hours, patient panel, etc) was limited.  Now, in a 5-physician private practice – I have great say about what hours I work and how we treat our patients.  But the care is not nearly as consistent!  I wonder how we can keep physicians going into primary care if we don’t give them the autonomy to create their own work-life balance?

  • Ellen Dibble

    The team approach among independent physicians and small groups, as it is done now, is by letters, if requested, I believe.  I think Blue Cross demands this, written reports from specialists to the primary doctor.  Presumably electronic transmissions and some standardization of what is transmitted will be helpful all around, and time-saving.  More paperwork?  Maybe.

    • Mary

      Well at least electronic reports /transmissions would mean that the notes of the doctor would be readable.. The joke about doctor’s handwriting is all too true.

  • Imorgenstern

    No question health delivery needs to be streamlined, but the comparison with Cheesecake Factory ignores a key reality. Cheesecakes inputs are largely consistent and predictable, whereas the patients in health care are each unique re symptoms, other conditions, etc. If inputs are consistent, it is far easier to have a consistent process and outcome. If the inputs are wildly different, it is very hard to have a consistent process or even comparable outcomes.

  • Scott192

    As my mother was dying in a Houston hospital, from an infection picked up in a previous hospital visit, several doctors came in at various times during her last hours and made different recommendations about her immediate care–in each case without even looking at her, just at the machines to which she was hooked up.  The last physician to come in actually looked at my mother, touched her, and said she was beyond help.  She died within minutes of that pronouncement.  I don’t know how this experience fits your guest’s thesis, but it was a disturbing, dispiriting experience.  My sister and I felt as if we were lost in a fog; we had no idea who to believe, or what to do. 

  • Leswp

    I work in a Family Practice near a city outside of Boston.  As a primary care provider I would love to have one person in charge.  The local hospital hired hospitalists and then forced the FPs, who used to round and coordinate care in the hospital out of the hospital by instituting rules requiring they visit with in a very short period of time/not allowing ER Drs to create admission orders.  This has fragmented care in a way that I have never seen in the 25 yrs I have practiced but has increased the hospital income.  There is now only one internal med guy that rounds.  It used to be over 20.  WOuld like to hear the Dr’s take on this.    

    • Leswp

      The other comment I have is that after being forced out of managing people in hospital we are now increasingly responsible for follow up after discharge despite no communication or accountability from those who provided care in house

  • Deborah Exo

    the family care doctor has NOT been coordinating care…when my husband calls his father’s family care doctor to discuss his overall care, the doctor can not speak to the specifics of the oncology doctor or the cardiology doctor. He does indicate that there is a letter in the file, which he has to go read but there is not conversation between the specialists and the family care doctor. When my father-in-law is in the hospital, the family care doctor did not come to the hospital…a letter was sent to the file upon his release. In addition, many family care doctors do NOT stay current so the care they do give is less than optimal. I applaud this change!

    • Leswp

      Our office would LOVE to be able to coordinate things and be in the loop.  The hospital has made that next to impossible with sidelining the Primaries who used to go in to see the patients even if it was just for a ‘courtesy call’.  Many of the conversations that occured in the past would happen when the Drs ran into each other or read notes when rounding.  Now the hospitalists ‘manage’ the care but make no effort to communicate the info with the Primary.  Just as described- the staff changes on a daily basis and although there is someone seeing the patient there is NO continuity.  Many times the patient is discharged and the notes are not complete for discharge for some time (blame the new computerized records that are so cumbersome that notes lag behind actual discharge).  Most of the time we find out the patient was discharged/ seen by a specialist only when they tell us.  We may not get information for days or weeks after the event.  None of the record systems communicate with each other.  We have no way of knowing when to seek information about what has happened as we don’t know it has. 

      Many people do not realize most practices are responsible for at least 3 thousand patients.  Large practices may have significantly more than that.  I used to work in a small practice early in my career.  We knew most of what is going on with our patient families.  As the practice grew this became less possible.  Sheer numbers make this almost impossible.  The very thing you are complaining about- lack of personal attention- is compounded when you make a system like the one being described. Unfortunately as we move to more volume vs quality this is guaranteed to be lost.   

  • Bill Fosher

    The Cheesecake Factory model of food service provision has at its heart the goal of reducing costs and increasing profits by producing a menu that can be heated up, rather than cooked, at the restaurant. The main way this works is by allowing lower-skilled workers can be employed on the front line. Is that what we want when we’re having a heart attack?

    • Tina

      No.  But some changes have been enacted in the past several decades that do make sense and cost less.  In my PARTICULAR CASE, I do not need to see my oncologist every month (maybe I would if my tumor markers were moving upwards at a faster rate), so I can see the Nurse Practitioner every other month, instead.  It helps that the NP is in a team with the oncologist.  

      I loved Rhode Island Group Health when it existed, and then I loved Harvard Health when we got switched to that.  WHY HH left RI is still a question that many of us can’t get an answer to.  Anyway, RIGHA and HH both worked with primary care physician teams.  The excellent secretaries were even trained in triage.  The whole time I was pregnant, I only waited in the office for a TOTAL of 45 minutes (TOTAL in 9 months!!!).  I could always immediately get in to see a NP or Physician’s Asst., if need be, who would always send me to see the physician when they thought it necessary.  When I first got my cancer diagnosis, they sent me to a local hospital-based cancer program where I got excellent care.  Walking down the hallways of the RIGHA/HH building was more like walking down a Main Street USA experience than going to my own town’s downtown:  the lab workers, the pharmacists, the primary care teams, the eye care workers and docs, you got to know them all, and they all were nice to patients.  I think they also had regular job schedules, so they were not called out on emergencies without warning.  They had regular schedules to be on the emergency alert.  Therefore, they had energy to give to patients, and were well-rounded as individuals and as professionals.  And ALL your care was coordinated and all in ONE chart:  even your eye care!  Everything was coordinated!  I never felt that anything was “managed” away from giving me the optimum in medical care (it was an HMO with a resident building.).

  • Ellen Dibble

    I missed some of the beginning, but I’ve heard Gawande before on OnPoint and read a previous article.  The list approach, it seems to me, needs constant updating, by any office, because medicine is changing.  Say the doctor who mostly does the researching and coordinating for the office points out that XYZ, and the nurses and everyone shift to that.  It happens all the time.  Different specialties would shift at different rates, depending how current and aggressive the office guide-people are.

  • Ellen Dibble

    For the primary care physician I go to (every couple of years, so not often), the actual pit crew chief is the nurse for my particular doctor.  I actually see any of three or four doctors if I show up.  But that nurse seems to know me.  She feels like a friend, and sort of knows how I use the knowledge and services there.  This may be my delusion, but it works for me.  I call, get her to call back, and feel that’s fine, all is well.

  • Anne

    What concerns me is that  there is no CARE in health care – it is a fragmented , disjointed system, a chain restaurant  model is also scary – there are so many variables with our patients  - crabcakes don’t have feelings and opinions.   As a physician I try to treat my patients like a family member,  While I understand that we need to follow algorithms, get feedback, improve constantly… What ever happened to  TALKING to patient and  FAMILY seems to be forgotten in this whole process. Going back, checking in, communicating – every person has  a different view of issues particularly around the end of life.    There is no way charge or reimburse for the time that it takes to communicate effectively with patients and families and other healthcare providers, so it doesn’t get done.   

  • Ellen

    It is a ridiculous idea to create “chair medicine” and turn medicine even more corporate than it already is.  

    Other countries such as France, Great Britain and Canada all have some form of publicly funded health care for all and they do fine — in fact, their costs are about half of ours per capita, and their results are better.  Let’s do what they do instead of emulating “The Cheesecake Factory!”

    • Tina

      Yes!  Hi!  Maybe On Point would do a show with experts who have studied the health care programs and policies of countries that:  1) have excellent health care for all, 2) have excellent economies overall.  These countries DO exist.  I think Sweden, Denmark, Finland, Norway can be counted.  Iceland screwed up for awhile, following the US Wall Street model, so it won’t do to say “the Scandinavian countries” for this project.  

      Once the countries (including any I haven’t mentioned, and not including the ones I have if I’m incorrect) have been identified, then it would be great to hear HOW their health care programs are structured:  everything about HOW they work.  We really don’t have to re-invent the wheel.  I know that we have more people than many of these countries, but that only makes learning HOW to do this MORE imperative.  Anyone can scale things up or down.  Difference in scale is just an excuse!  Also, if our system with a federal govt. and state govt.s isn’t parallel to the systems in these countries, we can still figure out HOW to make changes to accommodate those political-structure differences.  What are we:  too stupid to find models, modify models, and make things work by learning HOW to do something that is absolutely necessary for LIFE, LIBERTY, and HAPPINESS?!!! 

      I’ve come to think that the Biggest Political Difference in American life right now is this:  the Republicans want to turn absolutely Everything into a Market, so that they can Sell things for a Profit; or Charge Fees; or Sell Things requiring that people go into Debt thus generating Interest Payments.  They hate Government, because Government does not have to make a Profit.  Instead, it can operate At Cost and maybe charge a bit extra to Feed Back into The System to Make it Able to Improve Services in the Future.  The Republicans want those Government Services to be eliminated so that they can go back into what can then be considered a Market and fill in the gap with their various Money-Making Market Schemes.  This is NOT any environment for Health Care!!!  Yet, those who will be Least Well Served have been convinced that the Republican Way is best….

  • Ellen Dibble

    I think the best physicians say up front that patients have to be partners in their care.  A specialist I go to, we (a group of patients) spend hours together each week for various IV treatments, and we get to powwow together about things we’ve learned in our rather long lives, with rather interesting physicians in various countries, interesting conditions and treatments and responses, and then one or the other of us might have an appointment with the specialist and get some sort of answer, or we might find it on line.  That sort of thing.

    • Ellen Dibble

      I should say we often find solutions that health insurance will not cover, and have to sign off that no insurance of any sort will ever pay for this.  But on the other hand, what we end up paying is less than our health insurance would pay if we were going a more traditional route.  And our outcomes are far better — or else we wouldn’t be paying for it.  
          I don’t think the physicians are making as much money as they would be if they were practicing cookie cutter medicine, but by being cutting edge, at least in some dimensions, they are, well, very valuable.  The patients have to be either pretty desperate, willing or able to risk their dollars and time, or must be fairly well to do.  I think there will always be aspects of medicine that are not yet on the cheesecake menu; and to me, one pays for health insurance, and understands that one might not actually need cheesecake in your particular diet.

  • Ping1

    Chain medicine?  Sounds good…I can have a Walmart heart transplant in the future. Ah, the golden years

  • hvermont

    We don’t need Health Insurance, we need Health CARE!  The for profit model works great for restaurant chains, it is not appropriate for health care. 

    • William

       Most restaurant chains have a small profit margin where the health care industry has a huge profit margin. It seems odd that our economy works well except for health care. Electronics, telecommunications, car, travel, have all got cheaper, more efficient over the years, but not health care.

      • hvermont

        health care has a huge profit margin because they can get away with it.  it is not optional like electronics or travel.  When you are sick you NEED care.  When you have kids you NEED to have a doctor.  You are in a poor position to shop around for a better deal.  And is that what we want?  To be able to shop around for the best deal on treating our sick kid?

        • William

           Sure, every doctor should have a web page with prices posted. The free market seems to have skipped past doctors. If we imported more doctors just for family practice it would put more pricing power in the hands of consumers. It worked for almost all other industries in America so why not health care.

      • J__o__h__n

        The wine and beer markup is almost as bad as the that by drug companies.  Maybe undocumented labor can drive down doctor’s wages. 

  • Adks12020

    I’m 30 years old and haven’t had a primary care physician since I was in elementary school.  I always wonder why anyone, unless they have specific health problems, ever does.  I go to the doctor when I’m sick or injured.  Otherwise I don’t need a doctor.  Even if you have a primary care physician it’s almost impossible to get in to see them when you’re actually sick.  What good is a primary physician if you have a sinus infectino and can’t get in to see him/her for 4-5 weeks? I know I’m not the only one that thinks that way. Every time I see a doctor (which is very infrequently..once or twice every couple of years) they ask  me who my primary is and when I tell them I don’t have one they look at me like I have four heads. 

    • Adks12020

      what I was getting at is anything that is more efficient is a good thing in my book.

  • Village Grace

    What is the role of the “hospitalist” in this? Isn’t s/he supposed to provide the coordination and see to the continuum of care?

  • Kfritzdesign

    As a designer we always work with a team of specialists and generalists with a lead project designer is the main contact who coordinates the services provided.  I think we should compare this to how designers work where it is about client centered design as compared to chain restaurants where it is bottom line focused

  • Pre-optometry student

    Tom,

    I’m very concerned about the potential conflicts of interest that inevitably come up with corporate interests/profits involved.  For example, I can envision a chain of hospitals/providers being an investor in a particular drug company or specific drug and insisting, informally only, that their contracted doctors prescribe that drug over a competitor drug (not just generic vs brand name issue) and doctors that weren’t “team players” would be tracked and eventually not have their contracts renewed.  Of course, the reasons why these doctors weren’t renewed would never be that they didn’t prescribe the medicines that the investors/parent company also had an interest in, but for “other factors” and doctors would be facing the same employee discrimination rampant among other corporate employees in other industries.  Doctors would lose their freedom to act in the best interest of the patient, of course the corporation would deny this through their PR team.

    • Tina

      This is a very important post!! Thank you!!

  • Doug1029

    Teamwork teamwork teamwork.  Think Apollo 13.

    Three years ago, my wife was tossed out of her wheelchair on an uneven parking lot, breaking her femur above the knee.  A repair that should have worked failed because of lack of continuity of care.  The result: another more extensive repair, (what should have happened the first time) intermediate transitional care, and a more than doubled increase in cost to the system. 

  • Suttdenn

    I would like to see the health care system follow the construction industry model of a general contractor who is my contact point and he selects/recommends the tradesmen/specialists who have the best reputations and skills for my situation. This idea may work well for a hip replacement, but will breakdown when my care requires I leave my locale to access more advanced services.

    • Tina

      And there will still be change orders, and that’s where rigid protocols can break down.  Conception might find its parallel in new construction, but everything else is existing housing.  

  • Tina

    When my arm broke due to metastatic cancer, the Rescue Squad took me to the local trauma hospital which is across the street from the hospital I go to for cancer treatment (on purpose.  Even my cancer hospital staff said this was the correct choice).  The young doctor staff immediately took me off my regular medications, putting me on a cocktail of drugs they said would work at various levels.  These meds did no good, nor did the more extreme drugs they then put me on.  Eventually, they sent me home with a cocktail of medications including some across-the-counter type meds  which can wreck your liver which is a bad thing to court since cancer  mets can spread to the liver.  The cocktail was not effective.  And, once I was home, visiting nurses saw how crazy — really crazy — I was from the meds I was sent home with.  Eventually, one visiting nurse suggested that I stop taking this cocktail.  Suddenly, I wasn’t crazy and was soon able to feel much more comfortable.  The “protocol” that the young doctors were using was for a completely different population than the one I belong to:  people living with chronic metastatic cancer.  We are a new group, helped to live longer by new medications for both treatment and management of the disease; yet, these young docs applied some protocol that did not take my membership in this population into account at all! (By the way, there IS also a major cancer unit at the trauma hospital!!)

    Again, the two hospitals are across the street from one another; yet I suspect that they do not communicate on this matter in any useful way for the patient!  I did call an administrator at the trauma hospital, but I have no idea how seriously my comments were taken.  By the way, the young docs kept telling me that they were only giving me what they’d give their mother or grandmother, as if this compassionate approach underscored the wisdom of their dictum.  But listening to the patient:  that was sort of out of the question.  

    • Ellen Dibble

      I can imagine doctors’ egos are pretty fragile.  Not only are people’s lives and well-being their chosen responsibility, but things can get ugly quickly if lawsuits begin to occur.  Not only is a patient’s decline sad, for both, but actually threatening.  Hence, the defensiveness among physicians.  

  • jatal

    Dr. Gawande identifies key problems in health care and suggests important elements of a solution, the modern, well-designed industrial process, but I believe misses key differences between health care and industrial processes: 1) It’s much more complex than producing meals (Cheesecake Factory or McDonalds), delivering packages (Fedex), or successfully completing a commercial airline flight, more like banking (very “rational” but – oops). Following a very good guideline, which should be followed 60-80% of the time, is bad medicine 20-40% of the time. 2) High-quality care is multiple, distinct concepts: less “bad” variability, fewer errors, quicker uptake of good practices, more patient-centered care and more cost effective care. The Cheesecake Factory model addresses only a couple of these, but is likely to emphasize efficiency and variability/errors (but see above about guidelines), and consumers can’t evaluate health care but can evaluate meals and vote with their feet. 3) A successful process is collaborative; the process he describes in essentially top-down, not collaborative (yes, suggestions are entertained, but…). It’s an important contribution, but it just starts the process (and perhaps perpetuates inexact generalizations and incompletely thought-thru conventional wisdom). 

  • Debbera Drake

    RE: the team approach discussed on today’s program
    I receive health care from MIT Medical (my PCP) and Mass General.  My PCP and hospital caregivers communicate with each other whenever I have an appointment at either facility.  Both my PCP and my MGH caregivers report the appointment to the other, noting any findings or updates – keeping each other in the loop.  Though they are located in separate facilities, they are a team supporting my health.  At one point I was seeing my PCP when my oncologist called me; my PCP conferenced my oncologist in allowing my PCP, my oncologist, and my husband and I to talk together and make a decision together about clinical trial information.  We were team.Within MGH my nurse infusionist has paged my oncologist on several occasions, reporting responses I had to certain treatment aspects.  They are a team.Cudos to MGH and MIT Medical for focussing an a team approach.  It has been to my benefit for which my spouse and I are very grateful.Debbera Drake 

  • dianemurd

    I have two major concerns:  hospitalists replacing family doctors in the inpatient hospital scene who are coordinating care for someone they only just met and the overall ICU focus on the medical condition rather than the human condition.  Lewis Thomas, author of “The Youngest Science” shared these words about the process of his first personal experience with a kind of illness requiring hospitalization and high-intensity therapies, “…it was like being launched personless on the assembly line of a great (but quiet) factory. I was indeed handled as an object needing close scrutiny and intricate fixing, procedure after procedure and test after test, carted from one part of the hospital to another day after day until the thing was settled.  While it was going on I felt less like a human in trouble and more like a scientific problem to be solved as quickly as possible.  What made it work, and kept such notions as “depersonalization” and “dehumanization” from even popping into my mind, was the absolute confidence I felt in the skill and intelligence of the people who had hold of me.  In part this came from my own knowledge, beforehand, of their skill, but in larger part my confidence resulted from observing, as they went about their work, their own total confidence in themselves.”  While Dr. Thomas appears to find good things and bad about the modern, well-designed hospital industrial process, how does this make you feel?

  • Tina

    I think I have this right:  a few decades ago, some orthopedic surgeons had their own physical therapy divisions.  I don’t know if this practice were stopped at the federal, state, or professional level, but I believe I am correct in saying that it was stopped because it was felt that there was an economic advantage to be had by the doctor referring the patient to his own PT office.  Perhaps one patient didn’t really even need PT; etc.  

    Now, I’ve had to have two orthopedic surgeries.  There is nothing I’d like more when I go to see the orthopedic surgeon for follow-up visits than to see a PT right there who can check my gait and ROM, etc., with more musculoskeletal expertise  than even the surgeon has, and who could immediately talk with the surgeon and me if the PT had any concerns while I was right there in the office with the actual evidence, my arm, hip, whatever, there to be evaluated by both professionals.  That would represent the ascendency of actual bodily evidence over written objective and subjective notes as evidence, and, I submit, would result in optimum care.   Yet, because of the ethical issues I mentioned above, and the discontinuation of that linked system (surgeon/PT in one office), I’m not gonna get that medical service, and I will have to go to an outside PT.  That necessitates all sorts of extra administrative expenses, time, etc., and, again, that “system” uses notes to communicate rather than a shared professional experience, even when problems are noted.  I’m really saying that one of the best protocol-producing, protocol-following systems has already been ruled to be unethical, and I can see why.  But, I can also see how much easier AND more medically supportive it would be if those two medical areas could be in really close PHYSICAL relationship to one another.  

  • Petra

    Our organization, the Schwartz Center for Compassionate Healthcare, did a national poll a few years ago of 800 recently hospitalized patients and 500 doctors. Despite the fact that both patients and doctors expressed a strong desire for better coordination and continuity of care, 60% of patients said their PCP had not been in touch with them while they were in the hospital, 30% said they never met the physician in charge of their care before they entered the hospital, and a quarter of all patients said they did not know who was in charge of their care while they were in the hospital. It’s no wonder that so many Americans are disillusioned and dispirited about our healthcare system.

  • TribalGuitars

    We’re just too used to the status quo in this country.  There are always
    stories on the new about some revolutionary new procedure that’s
    better. It’s quicker, cheaper, less pain, quicker recovery, less
    invasive. But to get it someone would have stop their lives where they
    are and pay big money to go half away across the country and have the
    procedure.

     Look at the cameras that you can swallow instead of a
    colonoscopy. If the camera sees something a bit worrisome then a colonoscopy can be done for more detailed examination.  How many people don’t get a colonoscopy because of the prep, embarrassment, and discomfort involved, plus time off from work.  From the business end (pun intended), the costs of the Dr, the anesthesiologist, nurses, etc etc run into money. And the more a person waits the more money it will cost everyone – patient, provider, insurance, even taxpayers for those people that are uninsured – when what could have been found early  through a camera in a pill from the comfort of home, is now stage 3 colon cancer needing surgery, chemo, loss of income, and a loss of dignity and self for many.

    “For want of a nail the shoe was lost. For loss of the shoe the horse was lost…”  For loss of a small, ever more inexpensive, camera-pill people and money are lost every day.

  • http://massnurses.org/ Dschildmeier

    Hospitals are not factories, and patients are not cheesecakes, and Steward Health Care is no model for health care delivery in America, they are everything that is wrong with health care in America.  They are owned by Cerberus, a private equity firm that in addition to running hospitals, is also one of the largest gun manufacturers in the world.  Nurses, who spend more time with patients than any other provider and who have watched these business models and factory models (this is nothing new or innovative) be forced on clinicians and patients for the last 20 years can tell you that this approach does not work.  From a nurses’ perspective, assembly line practices means they are assigned more patients than they can safely care for and those patients are moved through the system quicker and sicker regardless of the needs of the patients or the capacity for nurses to provide the care these patients need.  We don’t need doctors and nurses stationed in bunkers looking at video screens monitoring patients, we need real nurses and physicians on the ground in these units observing patients and talking to them and caring for them in a way that we know works and works well.  Cerberus/Steward and Partners and all these other providers are not moving to these “assembly line” restaurant chain models of care to provide better care, they are moving to these models to provide care at a cheaper price, and in the case of Steward, their mission is to do this for their private investors.  Nurses, who are ethically and morally bound to advocate for their patients will not remain silent and pretend that this approach is either acceptable or effective. 

    • http://www.facebook.com/cynthia.a.pucci Cynthia Atwood Pucci

      thank you!  a clear headed and knowledgable response. bravo

  • Hennorama

    Individual physicians have struggled during the economic downturn just as other small businesses have.  Increased costs of insurance, and rapidly changing regulation make it difficult for individual doctors and small groups to cope with the changes.

    Hospital groups buying physician practices is only logical.  Vertical integration of health care makes sense, and will allow for economies of scale, and standardization of medical care.

    It’s not yet clear whether this will result in lower costs, higher standards and better outcomes, but it seems likely.  There are sufficient numbers of large hospital groups doing this that will allow for competition between them.

    However, it seems to me that the more apt comparison of The Cheesecake Factory and health care would be to look at retail medical clinics.  Use of retail medical clinics located in pharmacies and other retail settings increased 10-fold between 2007 and 2009, according to a recent RAND Corp. study.  These clinics can best be used for simple, easily managed acute conditions.  Cost is 30 – 40% less expensive than physicians’ offices, and 80% less expensive than emergency room care.

    Changing regulations, coupled with rising health care costs will result in many different models for providing care, but the trend toward larger organizations is clear.

  • Mike_Card

    I’m not a medical professional, but it scares the bejeezus out of me to hear one extolling the virtues of the edible assembly line.  What accredited medical school would grant such a misguided nincompoop a medical degree?  And what whack-job medical board would declare him fit to practice medicine?

  • Mike_Card

    This discussion is so old it makes me want to scream.  The only conclusion is that the MD’s are very interested in medical care, but they’re also very territorial.  They keep fighting among themselves, and refuse to compromise.  Much like today’s politics, and much like my remembrance of my parents’ GP, who was the county chairman of the John Birch Society.  If we leave it up to the MDs, no progress will be made.

    • http://www.facebook.com/cynthia.a.pucci Cynthia Atwood Pucci

      specifically the surgeons, who are like the kings (or so they think, and so does your insurance carrier, and so does the hospital because that is where reimbursements are highest)

  • Pointpanic

    so a chain restraunt is the answer to soaring health care costs in the US?NO model eliminating the profit motive will be considered?Hey are we CITIZENSS or mere consumers? Once againNPR aquieces to corporate America.

  • http://www.facebook.com/becky.vannocker.3 Becky Vannocker

    Becky Vannocker from Kansas City, Kansas.  My 81 year old mother had a stroke.  As we proceded through the maze of getting her into the hospital and through treatment at the hospital, I had to repeat the story of her medical history, medications, symptons, etc. at least 15 or more times.  Each nurse, technician, doctor, nurses aide dutifully wrote down my verbal statements, on computers or paper.  How is it that we have so much technology and not the ability to link various computers in the same hospital so this information can be accessed by workers instead of having to be repeated over and over again?  There should be a hospital wide link as well as linking hospitals in the same state.  Would it be too much to consider even linking together hospitals across the country?  I couldn’t help but wonder if the material was being recorded correctly each time…human error…

    • brettearle

      Medicine is still lagging behind Information Technology–partially–because many practicing MDs still resent technology or are even computer-phobic.

      They feel that they are being either upstaged, told what to do; or else their mistakes will be found out more readily…..mistakes, incidentally, that, sometimes, they MAY NOT EVEN REALIZE THAT THEY HAVE COMMITTED….but they KNOW they could have, or might have, committed…..

      • http://www.facebook.com/cynthia.a.pucci Cynthia Atwood Pucci

        this post is so far from reality it is difficult to even respond.  You have to learn a little more about hospital facilities and where the budget comes from and all the demands to improve infrastructure. Not to mention that doctors are there to provide one on one human information and real connections to patients and families, not sit in front of computers.  it’s the insurance companies who want the documentation –so they can decide whether or not you deserve the care and whether or not they will pay ……not so that you have a neat, tightly wrapped up book about yourself and your journey through the US Healthcare System

        • brettearle

          This reply, above, by Ms. Pucci, to my comment above hers, is indeed fairly far from reality, on its own–with regard to one of the major sources of the original problem.

          This assessment, of mine, has been confirmed by two hospitals–one of which is nationally famous, the other of which is world famous: 

          MDs have often, in the past, been behind the slowness of technology to improve quality of communication, within hospitals– for all kinds of reasons that have to with medical evaluation, diagnosis, treatments and decisions thereof.

          And, apparently, this resistance, for years, was a deterrent to technology being implemented and streamlined, within hospital environments, for functions that were only indirectly related to MD practice.

          Fortunately, this is changing.

    • http://www.facebook.com/cynthia.a.pucci Cynthia Atwood Pucci

      not surprisingly, when you first enter a hospital or a doctor’s office the information you give is incomplete. much like talking to a police officer or a detective, you leave a lot of detail out. Not to mention, it behooves you and everyone else not to think of the people in the hospital and the doctor’s office to understand that by and large the humans who occupy the facilities are not just computer technicians or ‘workers’.  In fact they are ‘people’ people.

  • hopeful61

    Off topic perhaps yet relevant.   As a self employed middle aged single female I pay almost $7,000 a year for health insurance that covers….nothing.  My “well” visit is covered and my other “well” check ups, eyes every two years etc.  But if I get SICK, or INJURED I have to satisfy my $2,000 deductible.  So we’re looking at $9,000 a year.   The last two years that this deductible came upon the scene, I have had to spend two hours on the phone each year fighting for my “well” yearly physical to be paid.  Because now with a deductible, suddenly the blood tests my physician has been ordering for the last 18 years as part of my “well” physical are “not medically necessary”.  And my “well” physical (where, by the way, you cannot have any complaints (e.g. don’t dare say you are tired!) or it becomes a “sick” visit, which goes to your deductible” that is supposed be free is now costing me $500.00.  This is in Massachusetts.  I am a healthy person and I cannot even imagine what very sick people have t go through. 

    I miss the good ole days, which seem not so long ago, when a person was sick or injured, you went to the doctor and did not have to worry.  No longer and this is a travesty. 

    I am glad that the Affordable Care Act will do away with the criminal act of insurance companies being able to deny care to human beings due to “pre–existing conditions” but as a self employed person I am not sure it will help with health insurance premiums and I anticipate if I remain self employed, it will cost me $15,000 a year to insure myself.  In the “land of the free”  Why is health insurance still tied to one’s EMPLOYMENT STATUS on in this country with an unemployment rate of 8%?  It doesn’t make any sense.  

    • brettearle

      What do you mean, “I miss the good ole days…..when a person was sick or injured, you went to the doctor and did not have to worry”?

      Family Practice MDs, back in the good ole days, missed many a symptom or played down many a symptom….did they not?

       

      • hopeful61

        Sorry, I guess good ole days was not the best choice of terms.  I mean as little as 5 to 10 years ago, if I was sick or injured, I called my MD and did not feel the need to call my insurance company to make sure it would be covered, etc.  If I needed diagnostic testing, it was usually covered.  I was buying my own insurance as an individual (around $350-450 back then) and there were no deductibles added to plans back then (well perhaps to extremely low cost plans).  The deductible seems to be a fairly new and now standard thing. 

        Now I AM injured and am hoping my injury will heal on it’s own so I don’t have to dole out another $2,000.  It seems like that $560 I pay per month is just money thrown out the window.

        • brettearle

          I am savvy about some things, in Medicine–but by no means an expert.

          However, it seems to me that the Affordable Care Act (ACA) may have retroactive provisions in it, as well as diagnosis-and- treatment–as–you–go provisions that might cover your problem.

          Like Medicare D, there’s the hackneyed expression, “Learning Curve”, that comes into play here:

          Those organizations and health professionals, who receive inquiries from the public–whether it’s insurance companies, the state and federal governments, or private agencies–have not become sufficiently apprised of ACA’s parameters or nuances, as yet.

          It’s likely to take a while–especially if some of these states opt out of the expanded coverage to the states provision….the aspects of ASA that are affected by the Supreme Court decision…..

  • http://www.facebook.com/lainie.castle.1 Lainie Castle

    Enjoyed the discussion today.  I came into the program when it was nearly over but am wondering where preventitive care falls with-in the chain medicine model?  The statistics are impressive for programs that promote wellness through  coverage that extends to more alternative care such as massage, accupuncture, etc., that the healthcare costs for major illness and time missed from work are reduced.  

    I am also wondering about the comment made regarding a supplement that is known to improve quality of life for migraine sufferers, yet only 13% of sufferers are aware or taking the supplement.  Do you happen to know the name of the supplement?

  • lpvgv

    I think one of the problems that causes the scenarios described in the New Yorker article is that physicians are taught to believe their “medical opinion” is equivalent to scientific facts, when indeed it is not. It is merely an opinion. Perhaps this explains why  treatments for the same malady can vary from one part of the country to another, or even across town. If treastments were based on science, wouldn’t they be pretty much the same? Obviously there is a lack of science in the practice of medicine. The irony is that implementing this chain model could bring more science into the picture. Science will help show which treatments are best, and good quality control (which is really a science based activity) will help make delivery of care better.

  • http://twitter.com/TongoRad TongoRad

    This is just another example of the main stream media bending over backwards to accommodate the needs of investment capital. 
    Workers need health care. We don’t need capitalist parasites.

  • http://www.facebook.com/cynthia.a.pucci Cynthia Atwood Pucci

    This concept of chain medicine and the author’s ‘branding’ ‘retail rollout’ and ‘Cheesecake Factory’ model is not new. This 1980s brought us all the ‘outpatient centers’ ‘satellite and ambulatory care centers’ and in his case ‘same day surgery’ centers.  The point of these in part is that it’s an easily identifiable service being provided to the patient, much like ordering off the menu. Why bother with the hospital?

    Spend a day in the life of a surgeon, especially one who does double time in the hospital and who runs his own private clinic and you’ll totally grasp the irrelevance of this ‘cheesecake’ perspective and also how it cannot work at the ‘healthcare system’ level. In other words, from a surgeon’s perspective, much like the chef’s, the patients are like the people sitting out at the dining room table waiting to be equally plated and served.

    As your second guest points out: patient CARE is much more demanding and in our current fixation with the total of health care delivery, and hospital reimbursement, etc, we’ve neglected to look at the very central role of the family practitioner.  i.e. “The Doctor” 

  • http://www.facebook.com/a.john.callegari A. John Callegari

    Am I to believe that Dr. Gawande believes that Dr. Girard’s private equity shareholders prefer “quality care” to greater profit with worse care and slick marketing?  I don’t think Dr. Gawande is that stupid based on his previous analysis and wish that Tom Ashbrook had been on his toes and called both of them out on this canard.

  • http://www.facebook.com/a.john.callegari A. John Callegari

    The great irony here is that the Cheesecake Factory provides food that would invariably destroy your health if you were to eat it regularly, yet it was invoked in a discussion of health!  Likewise, a profit-driven health system like Steward Health has no incentive to promote your long term health but plenty of motivation to provide you with mouth-watering bromides.  Dr. Gawande seems to believe that the government will be able to provide Steward Health with the proper incentives to create positive health outcomes.  If he were referring to almost every developed country, Dr. Gawande would be correct.  But in this country, the health care industry accounts for 15% of GDP and the profit from this industry pays for the (bribes) expensive campaigns of the officials that ostensibly would force them to pursue health over the easier goal of profit.

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Sep 17, 2014
Minnesota Vikings running back Adrian Peterson watches from the sidelines against the Oakland Raiders during the second half of a preseason NFL football game at TCF Bank Stadium in Minneapolis, Friday, Aug. 8, 2014. (AP/Ann Heisenfelt)

The NFL’s Adrian Peterson and the emotional debate underway about how far is too far to go when it comes to disciplining children.

On Point Blog
On Point Blog
Talking Through The Issue Of Corporal Punishment For Kids
Wednesday, Sep 17, 2014

On Point dove into the debate over corporal punishment on Wednesday — as Minnesota Vikings running back Adrian Peterson faces charges in Texas after he allegedly hit his four-year-old son with a switch.

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Our Week In The Web: September 12, 2014
Friday, Sep 12, 2014

In which you had varied reactions to the prospect of a robotic spouse.

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Beverly Gooden on #WhyIStayed
Friday, Sep 12, 2014

Beverly Gooden — who originated the #WhyIStayed hashtag that has taken off across Twitter — joined us today for our discussion on domestic violence.

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